<!DOCTYPE html>
<html lang="zh" xmlns:th="http://www.thymeleaf.org" >
<head>
    <th:block th:include="include :: header('新增押金补缴')" />
</head>
<body class="white-bg">
    <div class="wrapper wrapper-content animated fadeInRight ibox-content">
        <form class="form-horizontal m" id="form-payment-add">
            <div class="form-group">    
                <label class="col-sm-3 control-label">用户名：</label>
                <div class="col-sm-8">
                    <input name="synUserName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">效验码：</label>
                <div class="col-sm-8">
                    <input name="synKey" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">住院号：</label>
                <div class="col-sm-8">
                    <input name="inHosNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付类型：</label>
                <div class="col-sm-8">
                    <select name="payType" class="form-control m-b" th:with="type=${@dict.getType('his_pay_type')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易流水号：</label>
                <div class="col-sm-8">
                    <input name="payRecord" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">预交金金额：</label>
                <div class="col-sm-8">
                    <input name="payMoney" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付交易返回：</label>
                <div class="col-sm-8">
                    <input name="payReturn" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">支付状态：</label>
                <div class="col-sm-8">
                    <select name="successfulPayment" class="form-control m-b" th:with="type=${@dict.getType('his_payment_state')}">
                        <option th:each="dict : ${type}" th:text="${dict.dictLabel}" th:value="${dict.dictValue}"></option>
                    </select>
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">终端号：</label>
                <div class="col-sm-8">
                    <input name="terminalCode" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">商户订单号：</label>
                <div class="col-sm-8">
                    <input name="outTradeNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">微信订单号：</label>
                <div class="col-sm-8">
                    <input name="transactionId" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">商户id：</label>
                <div class="col-sm-8">
                    <input name="appId" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">床号：</label>
                <div class="col-sm-8">
                    <input name="bedNo" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">患都姓名：</label>
                <div class="col-sm-8">
                    <input name="patientName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">科室名称：</label>
                <div class="col-sm-8">
                    <input name="departmentName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">押金余额：</label>
                <div class="col-sm-8">
                    <input name="depositMoney" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">医保类型名称：</label>
                <div class="col-sm-8">
                    <input name="medicalTypeName" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultMsg" class="form-control" type="text">
                </div>
            </div>
            <div class="form-group">    
                <label class="col-sm-3 control-label">his接口返回信息：</label>
                <div class="col-sm-8">
                    <input name="resultCode" class="form-control" type="text">
                </div>
            </div>
        </form>
    </div>
    <th:block th:include="include :: footer" />
    <script th:inline="javascript">
        var prefix = ctx + "his/payment"
        $("#form-payment-add").validate({
            focusCleanup: true
        });

        function submitHandler() {
            if ($.validate.form()) {
                $.operate.save(prefix + "/add", $('#form-payment-add').serialize());
            }
        }
    </script>
</body>
</html>